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THE  NON-OPERATIVE  "TR'EATMEN'T'b'F 'SCOLIOSIS 

BY  WALTER  TRUSLOVV,  M.  D.      BROOKLYN,  N.  Y. 

;'  ill  approaching  what  is  perhaps  the  most  difficult  problem  in 
^Orthopedic  practice,  one  would  wish  to  be  clear  in  defining  the 
stbject.  This  paper  will  deal  with  true  rotary  lateral  curvature 
■  jf  the  spine — that  is,  with  the  well-known  deformity,  with  struc- 
tural changes.  Functional  scoliosis  must  be  dealt  with  carefully 
and  thoroughly,  but  is  not  the  bete  noir  that  structural  scoliosis 
is. 

It  is  necessary  also  to  understand  just  what  one  may  expect 
to  accomplish,  and  not  to  pre-suppose  what  at  present  seems  im- 
possible. Successful  treatment  of  rotary  lateral  curvature  of  the 
spine  contemplates  (1)  stopping  the  deforming  process,  (2)  ma- 
terially lessening  existing  deformity,  and  (3)  reasonably  assuring 
the  non-return  of  the  deformity.  The  present  writer  agrees  with 
tlie  findings  of  the  recent  Scoliosis  Committee  of  the  American 
If  Orthopedic  Association,  which  stated  that  no  known  method  had 
:^et  been  found  to  restore  to  body  symmetry  a  structural  scoliosis ; 
but  he  believes  that  the  ends  just  outlined  are  worth  striving  for 
and  are  attainable. 

Every  case  must  be  considered  individually;  but,  in  general, 
the  non-operative  treatment  of  structural  scoliosis  consists  in  a 
careful  weighing  of  the  indications  for  and  the  proper  use  of  (1) 
corrective  plaster-of-Paris  jackets,  with  pressure  paddings  and 
negative  window  spacing,  and  (2)  of  specific  intensive  exercises, 
with  retention  brace  or  corset — often  an  alternating  use  of  these 
means.  We  usually  state  our  procedure  in  treating  deformities, 
thus:  "Correct  the  deformity  first,  then  insure  its  non-recur- 
rence." Practically,  in  the  deformity  under  discussion,  we  find 
ro  means  completely  to  correct  the  deformity,  and  I  think  that 
nost  of  us  agree  that  there  is  a  very  definite  limit  to  the  forces 
V  hich  we  can  exert  on  the  individual  patient.  So  it  has  long  ap- 
peared to  the  writer  that  the  one  who  assumes  professional  charge 
of  these  patients  should  outline  a  procedure  which  should  allow 
the  use  of  both  means,  and  that  he  should  demand  for  himself 
•easonable  freedom  of  decision  as  to  when  either  should  be  used. 
Practically,  in  the  writer's  hands  an  alternation  of  the  plaster 
corrective  jackets  and  of  the  retention-muscle  training  has  often 
"'^een  most  effective. 

228 

57223^ 


*:  iivV-OPERA^lVli.iltljAtMKNT   OF    (SCOLIOSIS  229 

But  it  fe\6isi5lJcH*^tti*4tj\liie.*.jii^gment  of  the  one  in  charge 
must  be  formed  and  controlled,  not  only  by  his  observation  of  the 
patient's  varying  general  condition,  but  particularly  by  a  system 
of  measuring  of  the  specific  elements  of  deformity  which  should 
be  reasonably  accurate  and  yet  so  easily  applied  as  to  be  used  at 
each  change  of  plaster-of-Paris  jacket  and  at  monthly  intervals 
while  the  intensive  exercises  are  being  taken. 


FIG.  1— The  type,  right-dorsal  left  lum- 
bar, showing  deviation  of  spine,  low 
left  shoulder,  upper  trunk-lean  to 
the  right,  and  bulge  of  right-rear 
chest  and  of  left  low  torso. 


Fig.  2 — Adhesive  strip  placed  on  spine, 
record  of  deviation  and  of  carriage 
of  shoulders  marked  and  relation  of 
upper  trunk-lean  to  plumb  line 
shown. 


(Note:    In  the  pictures  of  the  model,     the     spinous     processes     have     been 
marked  to  show  the  effect  of  the  exercises.) 


After  first  hunting  for  and  eliminating,  if  possible,  unequal 
lengths  of  legs  and  congenital  bone  asymmetries,  the  writer  finds 
the  following  elements  of  deformity  necessary  to  recoi'd  at  regu- 
lar intervals: 

1.  Deviation  of  the  spine,  standing. 

2.  Relative  can-iage  of  shoulders,  standing. 

3.  Relation  of  lateral  upper  trunk  lean  to  a  spinal  per- 
pendicular, standing. 

4.  Deviation  of  spine,  in  prone  lying. 

5.  Rotation  of  spine,  in  prone  lying. 


230 


WALTER   TRUSl.aW 


They  can  be  recorded  in  f roni."  fivQ  'to. .ten  mirutes,  and  the 
succeeding  records,  rightly  studied,  are  exceedingly  valuable. 
The  patient  stands  with  back  exposed  from  neck  to  buttocks'  fold. 
(Fig.  1.)  A  strip  of  adhesive  plaster  is  placed  over  the  spinous 
processes,  from  seventh  cervical  to  first  sacral  (at  top  of  but- 
tocks' fold)  ;  the  successive  spinous  processes  are  palpated  and 
marked  on  the  adhesive  plaster ;  the  level  of  right  and  left  scapular 


Fig.  3 — Transferred  adhesive  strip, 
marking  the  spinous  processes,  the 
spinal  height,  the  shoulder  levels 
and  the  lateral  projection  of  sacral 
perpendicular  opposite  seventh  cer- 
vical vertebra  and  showing  the  meas- 
urements. 

angles  are  projected  and  marked  on  the  margins  of  the  adhesive 
plaster.  A  plumb  line,  representing  the  "sacral  perpendicular," 
is  then  hung  in  such  a  manner  that  its  weight  will  be  opposite  the 
buttocks'  fold  and  the  upper  end  to  right  or  left  of  the  seventh  cervi- 
cal marking.  (Fig.  2.)  Where  the  string  is  opposite  the  seventh 
cervical  point,  a  mark  is  made  on  the  adhesive  plaster.  To  make  a 
permanent  record  of  this,  the  adhesive  plaster  is  transferred  from 
the  patient's  back  to  any  flat  surface,  and  the  following  lines  drawn 
and  distances  measured.   (Fig.  3.)     A    line    is  drawn,  with  ruler 


•    'C10-\-OPEfe'A'i;[Y!5'T«E»\.TME>T   OF    SCOLIOSIS  231 

guide,  from""s\3V^h'th:dei'Vtc:al]to.'§i\si-sacral  dot.  It  is  called  "spinal 
height."  A  line  is  dra's\Ti  from  it  to  the  dot,  representing  greatest 
dorsal  deviation ;  another  to  greatest  lumbar  deviation.  Either 
marking,  for  scapular  angle,  is  projected  across  the  adhesive  strip, 
to  get  its  level  relative  to  that  of  the  opposite  scapular  angle. 
Measurements  are  taken  as  follows: 

a.  of  dorsal   deviation. 

b.  of  lumbar  deviation. 

c.  of  spinal  height. 

d.  of  relative  scapular  levels. 

e.  of  projection,  to  right  or  left,  of  seventh  cervical  vertebra 
to  sacral  perpendicular. 

A  history  sheet  record  of  the  above  reads,  for  example : 
Spine,  standing; 
Spinal  deviation  3.2  +  1.5  — 

=  .1044  or  101/2% 

45 
Carries  left  shoulder  3.3  lower. 
Carries  7th  cervical  1.6  to  the  right. 

The  above  is  a  record  of  certain  elements  of  deformity  in 
standing  or  weight-bearing  posture. 

To  obtain  a  record  of  bony  changes,  weight-bearing  must  be 
eliminated.  The  patient  is  placed  in  a  standard  position  prone 
upon  a  table.  Another  strip  of  adhesive  plaster  is  used  upon  the 
exposed  back  from  seventh  cervical  to  buttocks'  fold.  Succes- 
sive spinous  processes,  from  seventh  cervical  to  first  sacral,  ai"e 
palpated  and  marked.  Rotations  in  degree  are  obtained  by  the 
use  of  the  writer's  rotatometer.  (Fig.  4.)  This  consists  of  two 
hinged  arms,  with  a  recording  sector  fixed  to  one,  and  an  indicator 
fixed  to  the  other.  The  arm  with  the  fixed  sectoi-  is  placed  across 
the  back,  at  the  position  of  greatest  dorsal  rotation.  It  takes  such 
tilt  to  the  horizontal  as  this  back  transverse  may  give  it.  The 
arm  with  the  index  has  also  a  spirit  level.  This  arm  is  moved 
up  and  down  until  it  is  levelled,  and  the  degrees  of  rotation  are 
read  as  at  the  place  which  its  index  takes  on  the  sector  of  the 
other  arm.     The  greatest  lumbar  I'otation  (sector  arm  tilted  in 


232 


WAI.TKK   TIUSI.OW 


the  opposite  direction)  is  taken  in  the  same  way.  The  adhesive 
strip  is  transferred,  and  is  ruled  and  measured  for  spinal  height 
and  for  dorsal  and  lumbar  deviations,  as  when  taking  these 
measurements  with  the  patient  in  the  standing  position.  The  his- 
tory sheet  record  of  these  measurements  would  read,  for  example: 


Spine,  prone; 

Spinal  deviation  2.2  +  1.1 


=  .0733  (or  71/3%) 


45 


Rotations,  8  degrees  and  5  degrees. 


Fig.   4 — Writer's   rotatometer.     Note  arm   to  parallel   the  back    transverse,    the 
leveling  arm  and  the  sector  and  pointer. 


Comparison  of  the  relative  measurements  of  the  standing 
and  of  the  prone  positions,  of  the  amount  of  self-correction  pos- 
sible and  of  the  examiner's  correction  is  an  aid  to  prognosis,  but 
is  particularly  important  in  determining  how  effective  is  the  treat- 
ment, and  what  feature  of  deformity  correction  must  be  empha- 
sized in  continuing  treatment. 


JfON-OPERATIVE   TREATMENT   OF    SCOLIOSIS 


233 


Details  of  the  plaster-of-Paris  corrective  jacket  will  not  be 
dealt  with  at  this  time.  Effective  methods  of  procedure  are  well 
kno'WTi.  Each  surgeon  must  use  that  which  he  knows  best.  But 
some  features  of  technique  seem  worth  emphasizing.  First,  one 
must  have  a  very  clear  idea  of  the  elements  of  deformity  to  be  cor- 
rected. The  writer  finds  it  more  effective  to  depend  upon  the  ap- 
plication of  the  jacket  to  correct  the  faulty  upper  trunk-lean  and 
the  low  shoulder,  and  upon  the  exact  placing  of  subsequent  pad- 


FiG.  5 — The  starting  position.     I.  Kneeling 


dings  to  correct  the  spinal  deviations  and  the  rotations ;  rather 
than  to  emphasize  the  correction  of  all  deformity  elements  by  the 
position  of  the  patient  upon  which  the  jacket  is  built.  To  this 
end  the  hips-flexed  prone  lying  position  upon  the  hammock  in  the 
frame  is  chosen.  Before  plaster  dressings  are  applied,  the  pelvis 
is  fixed  and  then  the  upper  trunk  is  stretched  longitudinally  and 
in  such  a  manner  laterally  as  to  carry  faulty  upper  trunk-lean 
across  to  the  opposite  side  and  to  lift  the  low  shoulder.  This,  of 
course,  lessens  spinal  deviation  and,  to  a  slight  extent,  rotation ; 
but  the  emphasis  is  placed  upon  the  faulty  upper  trunk-lean  and 
the  low  shoulder.     Having  in  consideration  proper  counter  pres- 


234 


WALTKU  TBLSLOW 


SLires,  when  paddings  shall  be  used,  care  is  taken  that  the  trans- 
verse of  the  shoulders  shall  be  in  the  same  plane  as  the  trans- 
verse of  the  pelvis.  This  and  succeeding  plaster  jackets  are  dis- 
tinctly corrective,  but  pressure  forces  are  to  be  made  quite  within 
the  limit  of  comfort. 

Negative  window  spaces  are  cut  out  and  first  paddings  to 
correct  spinal  deviation  and  rotation  are  applied  in  two  weeks. 
Succeeding  paddings  are  applied  once  a  week  to  six  weeks  from 
the  application  of  the  plaster  jacket.  During  that  period  the 
plaster  rigidity  itself  prevents  any  further  correction  in  the  faulty 
upper  trunk-lean  and  in  the  low  shoulder ;  but  much  correction  of 
the  spinal  deviations,  of  the  rotation  and  of  the  anterior  rib  de- 


FiG.  6— Exercise  I.  1.  To  lessen  spinal  deviation,  hollow-back,  winged  right 
shoulder  and  rotation,  and  to  over  correct  low  left  shoulder  and  lateral 
trunk-lean. 


formities  may  be  obtained.  The  writer  emphasizes  this  point, 
as  he  believes  that  hazy  understanding  of  it  accounts  for  indif- 
ferent success. 

The  appointment  for  the  application  of  the  second  corrective 
jacket  must  allow  suflicient  time  to  take  the  measurements,  to  ap- 
ply the  plaster  body  mould  (a  rear  half  is  sufficient),  from  which 
a  cast  is  to  be  made  for  the  retention  brace  or  corset,  and  then  to 
apply  the  second  corrective  jacket.  The  patient's  position  for  the 
plaster  mould  for  the  brace  cast  is  also  hips-bend  prone  and  with 
over-correction  of  the  faulty    upper  trunk-lean  and  with  levelled 


XON-OPERATIVE   TREATMENT   OF    SCOLIOSIS 


235 


shoulders.  The  position  for  the  second  corrective  jacket  is  hips- 
bend  prone  with  marked  over-correction  of  the  faulty  upper 
trunk-lean  and  with  over-correction  of  the  low  shoulder.  Its  pro- 
gram of  four  to  six  weeks  is  similar  to  that  of  the  first  corrective 
jacket.  It  has  been  applied  in  greater  length,  to  meet  natural 
growth  plus  spinal  lengthening  due  to  lessening  of  spinal  devia- 
tion and  spinal  rotation.  During  the  wearing  of  it,  further  cor- 
rection of  deviation  and  of  rotation  and  front  chest  moulding  will 
have  been  accomplished. 

At  the  end  of  three  months,  the  figures  representing  spinal 
deviation  should  have  been  reduced  about  one-half  and  that  rep- 
resenting spinal  height  should  have  been  slightly  increased.     This 


Fig.  7 — The  starling  position,  11.  On  hands  and  knees. 


should  reduce  the  ratio  of  deviation  deformity  about  one-half,  or, 
for  example,  a  ten  per  cent  deviation  deformity  should  be  about 
five  per  cent.  The  upper  trunk-lean,  as  indicated  by  the  relation 
of  seventh  cervical  vertebra  to  sacral  perpendicular,  should  have 
been  carried  nearly  to,  or,  perhaps,  passing  across  the  vertical 
line;  and  the  shoulders  should  have  been  levelled.  In  this  time  it 
is  usually  possible  to  reduce  the  figures  indicating  rotations  also 
about  one-half.  Although  the  correcting  forces  have  been  but 
gradually  yet  steadily  applied,  and  although  the  cooler  months  of 
the  year  have  been  chosen  and  the  "scratcher"  faithfully  used 
daily,  the  patient's  skin  and  the  patient's  disposition  will  not  tol- 
erate more  than  three  months  of  these  jackets. 


236 


WAI/l'KK    TRUSLOW 


What  is  now  to  be  done?  We  know  that  much  of  the  de- 
formity will  recur  if  we  do  not  hold  what  we  have  attained  and 
so  train  the  muscles  by  intensive  exercises  that  they  will  increas- 
ingly be  able  to  assume  the  task  of  natural  support,  with  ever  les- 
sening artificial  support.  The  brace  or  corset,  planned  for  at  the 
time  of  changing  the  plaster  corrective  jackets,  should  now  be 
ready. 

A  truly  retaining  brace  is  difficult  to  attain,  but  is  important. 
The  requisites  are  (1)  ability  to  hold  correction  attained;  (2) 
"fool-proof" — the  patient  must  be  able  to  apply  it  with  reasonable 
accuracy;    (3)    extensibility  to   meet   normal   growth,   and   longi- 


FiG.  8 — Exercise  II,  1.     To  lessen  spinal  deviation  and  to  over  correct  lateral 
trunk-lean  and  low  shoulder.     Not  much  effect  on  rotation. 


tudinal  extensibility  and  lateral  compressibility  to  follow  further 
deformity  improvement  which  proper  exercises  will  surely  give; 
and  (4)  finally,  if  possible,  self-correction.  (The  writer  believes 
that  this  last  will  be  possible  by  the  use  of  a  laterally  bending  up- 
per segment  of  the  brace  and  a  stop-joint  to  prevent  bending  in 
the  directions  of  deformity  increase.  The  mechanical  difficulties, 
however,  are  such  as  to  make  a  presentation  at  this  time  of  what 
has  been  accomplished  premature) .  The  Knight  spinal  brace  can 
be  modified  to  meet  all  of  the  requisites  outlined,  except  self-cor- 
rection. The  brace  must  be  worn  by  night  as  well  as  by  day  at 
first. 


>"0.\-OPERATIVE    TREATMENT    OF    SCOLIOSIS  237 

With  the  removal  of  corrective  jackets  and  with  the  assump- 
tion of  the  retention  brace,  the  intensive  exercises  begin.  The 
brace  is  removed  for  the  exercises  only.  The  patient's  back  is 
exposed  for  all  exercises,  to  observe  every  detail  of  movement.  The 
starting  positions  are  in  kneeling,  on  hands  and  knees,  in  prone 
lying,  on  the  back,  half  prone  at  end  of  table  and  finally  sitting, 
to  insure  as  little  erect  weight-bearing  as  possible  and  because 
from  these  positions  best  concentration  on  the  parts  to  be  exer- 
cised is  obtainable.  The  muscles  must  gradually  be  trained  to 
assume  the  responsibility  of  weight-bearing.  As  the  muscles  get 
stronger  and  bring  the  superimposed  body  segments  nearer  and 
nearer  to  the  line  of  gravity  of  the  body,  the  artificial  support  of 
the  brace  is  less  and  less  used.  A  simple  reinforced  corset  be- 
comes possible.  The  relation  of  artificial  support  to  natural  sup- 
port may  be  expressed  by  the  schematic  diagram : 


Artificial  support ;  bracing 

Natural  support;  muscle  training 


The  exercises  are  classified   as    Preliminary    and  Deformity 
Correcting.     The  purpose  of  the  preliminary  exercises  is : 

1.  To  train  the  patient  to  take  the  starting  positions  and 
the  simplest  variations  accurately ; 

2.  To  'iimber  up"  the  stiffened  muscles  and  ligaments  of 
the  trunk,  the  shoulder  girdle  and  the  hip-joints;  and 

3.  To  start  the  correction  of  the  exaggerated  antero-posteri- 
or  spinal  curves. 

All  of  the  preliminary  exercises  are  symmetrical. 

I.  Kneeling. 

1.  With  hands  on  hips ;  trunk  bending  forward. 

2.  Alternate  foot  placing  forward. 

II.  On  hands  and  knees. 

1.  Alternate  head  and  mid-back  raising. 

2.  Trunk  swaying  forward  to  prone  lying,  then  back- 
ward to  resting  on  heels. 

3.  Alternate  thigh  extensions  backward  to  horizontal. 

4.  Alternate  arm  extensions  forward. 


238 


WALTER  TRUSLOW 


s«iiif'-immmmmimimm!smi'\ 


Fig.  9 — Exercise  II,  2.     To  lessen  spinal  deviation,  to  lessen  winged  shoulder 
and  rotation  (especially  lumbar)  and  to  lessen  hollow  back. 


Fig.  10 — Exercise  II,  3.     Powerfully  affecting  all  elements  of  the  deformity. 


NO.V-OPEKATIVE   TREATMENT   OF    SCOLIOSIS 


239 


III.  Prone  lying. 

1.  "Seal" — with  hands  clasped  low  behind  the  back; 
raise  head  and  shoulders  and  arms. 

IV.  Lying  on  back. 

1.  With  knees  drawn  up  (feet  resting  on  the  floor)  ; 
bend  both  knees  to  the  chest. 

2.  With  arm  stretched  upward  beyond  the  head ;  arm 
flinging  forward,  raise  trunk  to  sitting,  to  forward  reach  to 
toes. 


Fig.  11 — Exercise  III,  1.     To  lessen  winged  right  shoulder  and  to  develop  right 
vertebro-scapular  muscles.     Very  little  effect  upon  lumbar  deformities. 


horizontal      (knee 


V.     Half  prone  lying  at  end  of  table. 

1.  Alternate     thigh     raising     to 
straight) . 

2.  Raising  both  thighs  to  horizontal  (knees  straight). 

3.  With  arms  stretched  out  at  sides ;  raise  head  and 
shoulders  and  arms. 

VI.     Sitting. 

1.  With  feet  apart  and  dumbbell  on  floor  between; 
raise  weight  floor  to  right  shoulder,  to  high,  to  shoulder,  to 
floor,  to  left  shoulder,  to  high,  to  shoulder,  to  floor. 

About  a  week  is  sufficient    time    to  give    to  the  preliminary 
exercises. 


240 


WALTKR   TRf.SLOW 


The  intensive  corrective  exercises  are  progressively  based  on 
the  preliminary  exercises.  They  are  asymmetrical.  They  aim 
definitely  to  correct  the  specific  features  of  the  deformity  (See  Fig. 
1.) — the  upper  side  trunk-lean,  the  low  shoulder,  the  compound 
spinal  deviation,  the  exaggerated  antero-posterior  curves,  and  espe- 
cially the  rotations.  It  is  believed  that  this  is  accomplished  by 
actively  and  progressively  using  the  muscles  which  must  be  de- 
pended upon  to  maintain  these  corrections.  For  clearness  of  word- 
ing, the  type — right  dorsal  left  lumbar — is  here  chosen.  Modifica- 
tions of  the  following  exercises  must  be  chosen  in  variations  from 
this  type. 


Fig.  12 — Exercise  IV,  2.     To  develop  abdominal  muscles   (especially  of  the  left 
side)  and  to  affect  all  elements  of  the  deformity. 


Intensive  Corrective   (Rotation)  Exercises. 

I.     Kneeling.      (Fig.  5.) 

1.  With  cane  in  hands;  bend  trunk  forward  to  the  left, 
reaching  left  side  of  cane  far  forward  to  the  left,  carrying 
right  arm  (half  bent)  sideways  upward,  with  upper  trunk 
twist  to  the  right.    (Fig.  6.) 

II.     On  hands  and  knees.     (Fig.  7.) 

1.  Stretch  right  thigh  backward  and  left  arm  forward 
(synchronous  movement).    (Fig.  8.) 


NON-OPEKATIVE   TREATMENT   OF    SCOLIOSIS  241 

2.  Place  left  foot  forward  on  the  floor  and  raise  right 
arm  sideways  upward  with  upper  trunk  twist  to  the  right 
(synchronous  movement).    (Fig.  9.)      (Later). 

3.  Stretch  right  thigh  far  backward,  sway  trunk  back- 
ward (to  sitting  on  left  heel),  raise  right  arm  sideways  up- 
ward, twisting  upper  trunk  to  the  right  (synchronous  move- 
ment).   (Fig.  10.) 

III.  Prone  lying. 

1.  With  left  arm  forward  (to  the  left)  on  the  floor, 
head  resting  on  left  arm,  and  with  right  arm  out  sideways 
on  the  floor;  raise  right  arm  sideways  upward  with  upper 
trunk-twist  to  the  right.    (Fig.  11.) 

(Later,  with  increasing  dumbbell  weight  in  right  hand). 

IV.  Lying  on  back. 

1.  With  knees  drawn  up  (feet  resting  on  the  floor)  ; 
keeping  knees  parallel,  bend  toward  the  chest,  twisting  so  that 
knees  point  to  the  right  (feet  to  the  left). 

2.  With  arms  over  head  on  the  floor;  raise  trunk  to 
sitting,  to  left  hand  touch  to  left  toe  and  with  right  arm  rais- 
ing sideways  upward  and  upper  trunk  twist  to  the  right 
(synchronous  movement).      (Fig.  12.) 

V.  Half  prone  lying  at  end  of  table  (feet  on  floor) .  (Fig.  13.) 

1.  With  upper  trunk  placed  to  the  left  on  the  table,  left 
arm  reaching  far  forward  to  grasp  left  side  of  table  and  right 
arm  stretched  out  sideways;  raise  right  thigh  to  horizontal 
(knee  straight)  and  raise  right  arm  sideways  upward  (syn- 
chronous movement).     (Fig.  14.) 

(Later,  add  increasing  dumbbell  weight  in  right  hand.) 

2.  (Later)  Repeat  V.  1,  but  raising  both  thighs  to 
horizontal  (gradually  getting  an  increasing  twist  to  the  low 
spine,  by  elevating  the  left  hip  and  thigh). 

VI.     Left  thigh  support  sitting  on  bench — "spring  sitting." 

1.  The  left  thigh  is  supported  on  the  bench,  the  right 
thigh-leg-foot  is  stretched  far  backwai'd,  a  dumbbell  is  held  at 
each  shoulder;  bend  trunk  forward  to  the  left,  reaching  left 
arm  forward  (over  left  knee)  to  the  floor,  raise  right  arm 
sideways  upward,  with  upper  trunk  twist  to  the  right  (syn- 
chronous movement).    (Fig.  15.) 


242 


WALTER   TRUSLOW 


2,  Left  hand-suppoi't  "spring  sitting" — The  left  hand 
rests  on  a  table  far  forward,  the  remainder  of  the  body  in 
spring  sitting;  raise  right  arm  sideways  upward  with  upper 
trunk  twist  to  the  right.    (Fig.  16.) 

The  above  exercises  are  planned  with  the  least  apparatus  pos- 
sible, so  that  the  patient  may  do  them  at  home  daily.  Where  the 
operator  wishes  to  keep  entire  control  of  all  of  the  exercises  in  his 
crwn  gj^mnasium,  much  elaboration  will  suggest  itself  and  such  ap- 
paratus as  the  Swedish  plinth,  stall  bars  and  bom,  will  add  to  the 
effectiveness  of  much  of  this.  The  writer  outlines  an  exercise  pro- 
gram as  follows:   (1)  For  first  month,  at  office  gymnasium  once  a 


Fig.  13 — The  starting  position.     V.  Half  prone  lying  at  end  of  table. 

week,  (2)  for  second  month,  two  office  visits,  (3)  thereafter,  once 
a  month  at  office  gymnasium.  This  is  supplemented  with  a  writ- 
ten gymnasium  prescription  (GR  )  of  daily  home  exercises,  which 
is  added  to  usually  at  each  visit. 

Experience  has  shown  that  these  exercises  are  truly  corrective 
and  especially  of  the  rotation  deformity. 

Now,  to  estimate  the  relative  merits  of  the  three  procedures 
and  the  amount  of  time  to  be  given  to  each: 

1.  The  corrective  plaster  jacket  lessens  deformity  more  rap- 
idly than  does  brace-wearing  or  exercises.  It  affects  rotation  least 
of  all  of  the  elements  of  deformity.  It  has  distinct  time  limitation 
because  of  skin-pressure  intolerance  and  because  of  the  patient's 
attitude  toward  it.  It  must  be  re-assumed  after  a  shorter  interval 
of  bracing  and  exercises  in  the  paralytic  spine  patient. 


NON-OPERATIVE    TREATMENT    OF    SCOLIOSIS 


243 


Fig.  14 — Exercise  V,  1.  Passively  correcting  low  shoulder  and  upper  trunk-lean 
and  hollow-back,  and  lessening  spinal  deviation;  actively  lessening  winged 
right-shoulder  and  rotation. 


Fio.   15 — Exercise   VI,   1.     Actively  affecting  all   elements  of  the  deformity,   but 
especially  spinal  deviation  and  rotation. 


244 


WAI/IKR   TIUSI.OW 


2.  The  retentive  brace  alone  will  delay  deformity  formation. 
It  will  bring  about  no  correction  of  it,  and  unless  constantly  cared 
for,  will  allow  increase  in  deformity.  It  is  inadequate  in  the 
paralytic  spine. 

3.  Exercises  alone  will  not  be  sufficient  to  prevent  an  in- 
crease in  a  deformity  in  which  the  ratio  of  deviation  is  greater 
than  four  per  cent.  It  must  be  used  with  very  gradual  progres- 
sion in  the  paralytic.  When  reinforced  by  an  efficient  retention 
brace  and  intermitted  with  an  occasional  short  return  to  the  cor- 
rective jacket,  it  is  the  best  means  available  for  insuring  a  stopping 


Fig.  16 — Exercise  VI,  2.  While  passively  correcting  spinal  deviation,  low 
shoulder  and  upper  trunk  lean,  to  concentrate  actively  on  lessening  winged 
shoulder  and  rotation. 


of  deformity  progress,  for  insuring  a  large  amount  of  deformity 
lessening,  and,  by  its  general  hygienic,  as  well  as  local  effect,  for  a 
reasonable  assurance  of  non-return  of  deformity. 

As  to  time  necessary,  one  would  say  that  a  structural  scoliosis 
presenting  five  per  cent  deviation  or  less  would  require  about  one 
year  of  active  treatment — plaster  corrective  jackets  for  three 
months,  nine  months  of  retentive  brace  and  intensive  supervised 
exercises;  and  that    in    the    second    year    a   girl    could  wear  a 


NON-OPEBATIVE   TREATMENT   OF    SCOLIOSIS  245 

simpler  reinforced  corset  and  do  her  home  exercises  daily,  with 
occasional  supervision  of  the  doctor.  A  ratio  of  deviation  of 
five  to  ten  per  cent  would  require  three  months  of  corrective 
jackets;  six  months  of  retentive  brace  and  intensive  exercises; 
three  months  of  corrective  jackets,  and  a  second  year  of  bracing 
and  supervised  exercises.  Greater  amounts  of  deformity  would 
require  longer  time.  The  paralytic,  if  treated  non-operatively, 
must  have  a  larger  proportion  of  the  time  given  to  the  cor- 
rective jacket  and  must  be  carried  on  for  several  years. 
Summary : 

1.  Successful  treatment  of  structural  scoliosis  must  depend 
upon  a  clear  understanding  of  the  elements  of  deformity,  and  the 
lessening,  if  not  complete  elimination,  of  all  of  them. 

2.  Uniform  and  regular  measurement  and  numerical  record 
of  the  elements  of  deformity  are  important  as  guides  to  continu- 
ance of  treatment  and  as  indicating  elements  most  needing  cor- 
reoion. 

3.  A  balanced  use  of  corrective  plaster-of-Paris  jackets,  of 
retention  brace  and  of  intensive  exercises  is  essential  to  satisfac- 
tory results. 

4.  The  position  of  the  patient  when  the  plaster  jacket 
is  applied  is  responsible  for  improving  body  posture  and  shoulder 
carriage ;  the  successive  paddings,  for  care  of  the  spinal  deviation 
and  the  rotation. 

5.  Essentials  of  a  retention  brace  are  (a)  ability  to  hold 
correction  attained;  (b)  application  by  the  patient  with  reasonable 
accuracy;  (c)  extensibility  and  lateral  compressibility  to  meet 
normal  growth  and  progressive  deformity  decrease;  (d)  mechani- 
cal self-correction  by  the  brace  seems  possible,  but  not  yet  fully 
attained. 

6.  Gymnastic  exercises  must  be  progressive,  intensive  and 
with  a  minimum  of  erect  weight-bearing.  They  must  aim  to  cor- 
rect all  of  the  elements  of  deformity,  especially  that  of  rotation. 
Starting  positions  other  than  standing  facilitate  these  ends. 

7.  Retention  of  deformity  correction  attained  must  be  main- 
tained while  exercise  is  developing  natui'al  muscular  support. 
Artificial  support  may  gradually  give  way  to  natural  support. 
The  paralytic  scoliotic  must  receive  a  larger  proportion  of  arti- 
ficial support  than  will  be  required  for  those  not  paralyzed  in  the 
trunk  muscles.  Internal  splinting,  by  operative  bone-fixation, 
may  also  be  necessary  in  severe  paralytic  cases. 


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